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Original Investigation
November 2016

Assessing Cardiovascular Risk to Guide Hypertension Diagnosis and Treatment

Author Affiliations
  • 1The Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
JAMA Cardiol. 2016;1(8):864-871. doi:10.1001/jamacardio.2016.2861
Key Points

Question  How should results from recent blood pressure intervention trials be applied to appropriately treat patients with elevated systolic blood pressure?

Findings  More than 73.1 million US adults have elevated systolic blood pressure (120-139 mm Hg), many of whom are at high risk for cardiovascular disease (CVD); however, only a few high-risk adults would have qualified for the Systolic Blood Pressure Intervention Trial. If hypertension treatment were initiated for systolic blood pressure of 120 mm Hg or higher in adults with prior CVD or at high risk for CVD (risk ≥15%), 5.8 million untreated adults would require treatment initiation and 8.5 million would require medication intensification.

Meaning  Clinicians should consider CVD risk in addition to blood pressure measurements alone to guide blood pressure treatment recommendations.


Importance  The Systolic Blood Pressure Intervention Trial (SPRINT) demonstrated the benefit of lowering systolic blood pressure (SBP) to 120 mm Hg, yet other trials, such as Heart Outcomes Prevention Evaluation–3 (HOPE-3), did not find consistent benefit. How to incorporate these results into the treatment of those with elevated SBP in the general population is not clear.

Objectives  To assess the representativeness of SPRINT and HOPE-3 relative to patients in the United States and to explore the cardiovascular disease (CVD) risk profiles of various populations with elevated SBP.

Design, Setting, and Participants  The study examined data from nonpregnant adults aged 20 to 79 years participating in the 2007-2012 National Health and Nutrition Examination Survey (NHANES) who had complete data available (n = 14 142), representing 206.9 million US adults. The study was performed from October 1, 2015, to August 2, 2016.

Main Outcomes and Measures  The study estimated the number and characteristics of adults with SBP of 120 mm Hg or higher, including SPRINT and HOPE-3 eligibility, and estimated who may have newly required treatment initiation or intensification if various trial or risk-based criteria were applied.

Results  NHANES included completed clinical evaluations from mobile examination centers on 15 974 adults aged 20 to 79 years (mean [SD] age, 45.9 [15.5] years). The study excluded 182 pregnant women and 1650 adults in whom CVD risk data were unavailable, leaving a final study population of 14 142 (50.5% women [95% CI, 49.6%-51.3%] and 49.5% men [95% CI, 48.6%-50.4%]). An estimated 53.3 million untreated and 19.8 million treated US adults have an SBP in the diagnostic and treatment gray zone (120-139 mm Hg), a small proportion of whom would have been eligible for SPRINT (5.4% untreated, 13.9% treated) or HOPE-3 (13.9% treated, 1.7% untreated). Even among those with prior CVD or high risk of CVD and elevated SBP (120-139 mm Hg), only a few would have qualified for SPRINT (27.0% and 21.9% of untreated and treated patients, respectively) or HOPE-3 (10.6% and 2.1% of untreated and treated, respectively). If blood pressure treatment recommendations were extended to adults with an SBP between 120 and 139 mm Hg, as well as prior CVD or CVD risk of 15% or higher, then 5.8 million untreated adults would be reclassified as treatment eligible; furthermore, 8.5 million treated patients would require medication intensification.

Conclusions and Relevance  Millions of US adults have elevated SBP and high CVD risk, most of whom would not have been eligible for SPRINT. Until more definitive evidence becomes available, clinicians should consider a management paradigm based on CVD risk in addition to blood pressure measurements.